Delaware River Yachtsmen’s League
Bud Koch Poker Run –June 21, 2014 Entry Form
Please Fill Out And Hand In At Your Starting Point ( Bristol YC - Farragut SA - West End BC)
Name of Player : ______
Club : ______
Address : ______
City : ______State : ______Zip : ______
Phone # ______Mobile / Cell______
Player Entry Fee - CircleChoices:
$20.00 (NO EXTRA CARD ) $5 (EXTRA CARD ) $5 ( LOSERS POOL )
TOTAL PAID ______
Where Will You Be Starting At? BYC_____ FSA_____ WEBC _____
Boat Info
Boat Name : ______
Captain’s Name : ______
Boat Club : ______
Insurance Company : ______
Policy # : ______Expiration Date : ______
I CERTIFY THAT THE ABOVE NAMED BOAT IS INSURED FOR THIS EVENT FOR PUBLIC LIABILITY AND PROPERTY DAMAGE.
Captain’s Signature ______
In respect of the members/organizers of the Delaware River Yachtsmen’s League POKER RUN accepting this application, the undersigned for myself, my heirs, executors, administrators, and assigns hereby release and agree to indemnify and hold harmless the members of the Delaware River Yachtsmen’s League POKER RUN, its organizers, sponsors, committee officials and each of their respective servants, agents or employees from any claims, damages, demands, actions, or causes of action arising out of or in consequence of any loss, injury, or damage to my person or property incurred from any cause whatsoever, in consequence of attendants or participation in the Delaware River Yachtsmen’s League POKER RUN event notwithstanding that any such loss or injury may have arisen by reason of negligence of members of the Delaware River Yachtsmen’s League POKER RUN, its sponsors, organizers and committee officials or any of their respective agents, servants or employees. The undersigned further agrees to hold the said members of the Delaware River Yachtsmen’s League POKER RUN, its sponsors, organizers and committee officials harmless and does hereby indemnify them from any and all liability for personal injury or property damage to third parties which may occur in any manner arising out of my attendance at or participation in the said Delaware River Yachtsmen’s League POKER RUN event. The undersigned further acknowledges that the Delaware River Yachtsmen’s League POKER RUN is not a race and that speed shall in no way determine the outcome of the Delaware River Yachtsmen’s League POKER RUN event and hereby agrees to abide by all the rules, directives, terms and conditions of the Delaware River Yachtsmen’s League POKER RUN event, as set forth by any of the organizers and/or committee officials, either verbally or in writing, before or during the Delaware River Yachtsmen’s League POKER RUN. The undersigned further agrees that the boat named in the application for entry is in safe operating condition and complies with and meets and is equipped with the prescribed equipment and requirements of the small vessels of the United States Coast Guard.
I Have Read the Above & Agree With The Conditions Set Forth.
Player’s Signature : ______Date : ______
Captain’s Signature : ______Date : ______